PROVIDENCE – The first meeting of the R.I. Health Insurance Small Employer Task Force since the departure of former R.I. Health Insurance Commissioner Christopher F. Koller proved disquieting to a number of the small business leaders attending.

The featured speaker at the sparsely attended gathering on Oct. 8 at Temple Beth-El was Dr. Kathleen Hittner, the new Health Insurance Commissioner. She shared her future vision, offering policies and views that appeared to diverge sharply from Koller’s on a number of important issues.

Since her appointment by Gov. Lincoln D. Chafee, who lured her out of retirement to replace Koller, Hittner had already made the rounds as a speaker, appearing on panels at numerous summits in the last month. Her appearance before the task force, a veritable creation of her own agency, appeared to be more of an afterthought, not a priority.

Tricia Leddy, deputy director of HealthSourceRI, followed Hittner to the podium, and she exhorted the 30 or so business leaders in the audience to become “ambassadors” for the new health exchange.

Leddy’s talk made apparent the changed nature of the relationship between the task force and the Office of the Health Insurance Commissioner: small businesses were now being asked to perform as boosters for HealthSourceRI.

Leddy’s proposed role did not sit well with Donald R. Nokes, president of the Rhode Island Business Group on Health, who told ConvergenceRI after the session that he was puzzled by this move.

“What is the Small Employer Task Force’s connection to HealthSourceRI?” Nokes wondered out loud. “Why is the task force being asked to be the pom-pom cheerleaders for HealthSourceRI?”

Nokes said that the cheerleading role was far different than his understanding of the original purpose of the group.

Another task force member, stunned by Leddy’s pitch, speaking more to herself than anyone else, blurted out in a surprised realization: “There’s no role for us to do anything.”

A short history lesson
In early 2012, Koller used his agency resources to pay to organize a group known as the R.I. Health Insurance Small Employer Task Force.

The idea was to create a public forum for small businesses in Rhode Island, giving them a regular opportunity to meet and, in an orchestrated fashion, provide a bully pulpit to voice their frustrations over the ever-escalating premium rate hikes for health insurance.

In a Machiavellian way, Koller was well aware that he, as R.I. Health Insurance Commissioner, was creating a pressure group that would seek to influence the rate-setting outcomes for health insurance premiums.

Marti Rosenberg, program director of the Providence Plan, was hired to organize the group, and Dyana Koelsch, president of DK Communications, was hired to do the communications and outreach, often serving as emcee at the meetings. Both Koelsch and Rosenberg were still performing those same tasks at the Oct. 8 meeting.

Koller also recruited three health-related business groups – the Small Business Association of New England, RIBGH, and HealthRIght – to be participants in the task force.

The task force’s initial meeting, held on Feb. 2, 2012, at the Rhode Island Foundation, began as a pedantic show-and-tell led by Koller and Michael Bailit, a health care reform expert, to explain the rudiments of health care reform to small businesses

The tenor of that meeting dramatically changed when Valerie Ann Leduc, vice president of operations at Angelo’s Civita Farnese restaurant on Federal Hill, spoke up.

Her company’s health insurance rates had just jumped 22.8 percent for 2012, Leduc explained, but because she was a small employer, she couldn’t get any information about the exact reasons behind why the costs had escalated so dramatically.

“We were planning on an increase [of about 10 percent], but it’s hard to make massive changes in your business plans in 30 days,” she said.

“Wow! How can I get in touch with you?” Koller responded for the podium. Leduc provided him with her business card, and she was then recruited to become a member of the task force’s ad hoc leadership group.

Over the course of the next six months, the task force held numerous public meetings, including one at the Rhode Island Shriners and Imperial Room in Cranston, which drew all three CEOs of Rhode Island’s commercial health insurers – Peter Andruszkiewicz of Blue Cross & Blue Shield of Rhode Island, Jim Roosevelt of Tufts Health Plan, and Stephen Farrell of UnitedHealthcare of New England.

The task force’s apogee that first year was at a meeting, held in September of 2012 at EpiVax, Inc., attended by both Gov. Lincoln D. Chafee and Lt. Gov. Elizabeth H. Roberts, where Koller announced his rate decisions regarding the 2013 health insurance premiums for commercial insurers.

Koller said at that gathering that his decision reflected his efforts to cap increases in medical expenses at 4 percent as well as to respond to concerns voiced by businesses on how increases in health insurance costs were injuring their ability to compete. As a result, employers in Rhode Island could expect average premium increases limited to a range of 1.65 percent to 5.53 percent, according to Koller.

However, Blue Cross appealed Koller’s rate decision, and was eventually granted permission to raise it rates to reflect the higher medical utilization costs.

As an apparent trade-off, responding to pressure from RIBGH, Blue Cross agreed to make future contract information regarding costs paid to providers more transparent.

Hittner’s vision, looking foward
Hittner began her presentation by sharing a story about growing up in Pennsylvania and working in the family business growing mushrooms – her father had an exclusive contract with Cambell’s Soup to grow mushrooms for their products.

Predictability was important to the success of the mushroom business, Hittner explained. And, Hittner promised that she would deliver “predictability” to health insurance rates and premium increases. But, she added, small businesses should not expect to see those premiums go down anytime soon in the next few years.

In other words, “predictability” in the short term may mean that many small businesses would be likely to continue to experience premium increases for the immediate future.

Hittner said that she was opposed to the concept of any cost caps for health care insurance premiums, even though she, along with Secretary Steven Costantino of the R.I. Executive Office of Health and Human Services, serves as co-chair the R.I. Health Care Planning and Accountability Advisory Council.

That group has been charged by the R.I. General Assembly with quantifying the “total spend” of the state’s health sector, to help evaluate whether Rhode Island should set an annual target of total health care spending tied to the overall growth of the state’s economy.

In other words, even before the costs are quantified and the facts were compiled by the Council, Hittner has staked out the position that she is opposed to the idea of caps. One of her primary responsibilities, she explained, is keeping the health insurers solvent.

Koller had expressed a different take on the issue. “Understanding what drives total medical expense is essential to developing good policies and plans,” he said, in an interview in May, talking about the priorities identified for the Council.

According to Nokes, the Office of the Health Insurance Commissioner was already working under cost caps, to some degree.

“I think we are actually working within cost caps today,” Nokes told ConvergenceRI. “The insurers are told that they can’t spend any more than 15 percent of their intake – what they grab from people – on administrative costs. The rest of the 85 percent has to be used to pay for medical claims.”

Nokes believes that escalating medical costs are the cause of escalating rates. “I would love to find a way to cap those costs,” he said.

Hittner said she would look into the feasibility of a suggestion made by Ted Almon, co-chair of HealthRIght, to consider moving premiums, co-pays and deductible expenses into one consolidated transaction that HealthSourceRI could manage.

Hittner also discussed her ideas of expanding the reach of the R.I. Chronic Care Sustainability Initiative, known as CSI-RI, by bringing hospitals to the table and including them.

Curently, CSI-RI is an initiative targeted at adults with chronic conditions, seeking to have their primary care needs addressed through a patient-centered medical home. The program, supported by all the commercial and government payers, currently involves more than 200,000 Rhode Islanders who are currently being served through primary care practices that are patient-centered medical homes. Many of the patients, however, are unaware that they are being seen as part of a patient-centered medical home. 

Blue Cross, for its part, has invested some $60 million to support the development of patient-centered medical homes in Rhode Island.

Exactly what role the hospitals would play as part of the initiative was not made clear by Hittner, other than she had already begun negotiations with one hospital system in Rhode Island about their participation.

Hittner also proposed that another way to potentially cut medical costs was to promote CurrentCare, the state’s health information exchange, to every person who buys insurance through HealthSourceRI.

Hittner said that she had talked with Christy Ferguson, the executive director of HealthSource RI, and that there was tentative agreement to try and move ahead with this proposal.

The goal of CurrentCare is to enable providers to access an up-to-date electronic databank of a patient’s health records. Administered through the Rhode Island Quality Institute, CurrentCare has had trouble attracting Rhode Islanders to participate, with only about 330,000 enrolled to date.

Hittner appeared to be unaware that there were other problems with CurrentCare beyond its ability to sign up participants. For instance, the actual number of continuity of care documents available for patients through CurrentCare is said to be much less than the number who have joined – under 200,000, according to one source. In July, a former Rhode Island Quality Institute employee told a State Innovation Model committee that it was only about 19,000.

In addition, the electronic interface between CurrentCare and some proprietary Electronic Health Record software packages has reportedly proven more difficult to resolve than expected, with the glitches still needing to be worked out, according to a number of sources.

Blurred lines, conflicting roles
In the aftermath of the task force meeting, it was clear that its future purpose under Hiittner’s leadership was not to continue to be an organized voice for small businesses to advocate for slowing the escalation of health insurance rates, but to serve as a proselytizer for the state’s efforts to implement health care reform.

An e-mail message from Rosenberg following the meeting made the change in purpose explicit. It said: “We look forward to continuing our work with you to improve our health care system. I’ve attached the form that we handed out today, to get information from you as to where you think the Small Employer Task Force can be out in the community, giving presentations.”

It also highlighted the blurring of lines that can exist between state agencies in Rhode Island, such as between the Office of the Health Insurance Commissioner and HealthSourceRI.